Prior Authorization Coordinator

Overview : The Prior Authorization Coordinator will facilitate logging in and out of all prior authorization, appeal, reimbursement and grievance requests, and follow‑up on requests to ensure they are resolved and completed in a timely manner.

The coordinator will ensure that all steps involved with the process are completed and all regulatory requirements are met or exceeded.

They will also be responsible for the pharmacy medical exception line to address provider questions regarding the formularies for all lines of business serviced by Pharmacy Benefit Dimensions.

The coordinator will also provide high‑quality, diverse administrative support including, but not limited to, faxing prior authorization requests, completing decision letters by faxing and copying, making decision notification phone calls to members and physicians, filing, and document scanning preparation.

Occasional holidays, weekends and overtime will be a requirement of the position.

Qualifications

• High school diploma or GED required. Associates degree preferred.
• Two (2) years of experience in pharmacy or health insurance operations required OR one (1) year of experience as a temporary associate in the Prior Authorization Coordinator role or Prior Authorization department required.
• Pharmacy experience strongly preferred.
• General knowledge of drug names, therapeutic categories, dosage forms, manufacturers and packaging preferred.
• Familiarity with HMO concept.
• Experience with pharmacy on‑line system preferred.
• Written and verbal communication skills.
• Excellent organizational and time‑management skills.
• Excellent ability to absorb new concepts and adapt to a changing environment.
• Exhibit creativity and self‑motivation, with the ability to effectively solve problems as they arise.
• Demonstration of math aptitude for purposes of calculating simple drug requirements when given dose and price calculations.
• Proven examples of displaying the PBD values: Trusted Advisor, Innovative, Excellence, Guardianship, Dedication and Caring.

Essential Accountabilities

• Assist Clinical Review Pharmacist in making appropriate decisions by verifying member and provider eligibility and filing requests into the correct member folder according to set standards.
• Enter data and ensure complete accuracy on all statistics by logging prior authorization requests into pharmacy systems according to set standards.
• Complete the requests by entering override into the appropriate pharmacy system and updating all information in required documentation systems according to set standards.

May also include transcribing Medical Director decision into systems.

• As volume dictates, timely and accurately complete various reports, reimbursement requests, IRO and review of vendor emails/reports as assigned by the Supervisor.
• Facilitate follow‑up phone calls to members and providers for clinical approvals and denials according to set standards.
• Initiate outbound telephone calls to members/physicians regarding decisions within all regulatory time frame requirements.
• Answer and provide resolution to provider and internal callers regarding formulary/prior authorization questions for all lines of business.

Log all calls into call documentation systems.

• Research and respond to escalated and complex inquiries regarding Pharmacy questions or concerns.

Ensure that all callers obtain accurate and up‑to‑date information on policies and procedures and communicate a successful resolution to inquiries.

Provide callbacks when necessary.

• Provide support for all required letters within the required timeframes.
• Fax prior authorization requests including requests for additional information and completed requests.
• Copy and mail completed requests and related documents.
• Prepare completed requests for scanning into documentation systems.
• Maintain proper storage of all files, in accordance with the corporate retention policy.

Immigration or work visa sponsorship will not be provided for this position.

Hiring Compensation Range : $22.00 hourly.

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off.

The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity /Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant’s race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.

Click here for additional EEO/AAP or Reasonable Accommodation information.

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